Neurological Function In Patients Research Articles

Osmotic Shifts, Cerebral Edema, and Neurologic Deterioration in Severe Hepatic Encephalopathy.

We sought to determine the effect of acute electrolyte and osmolar shifts on brain volume and neurologic function in patients with liver failure and severe hepatic encephalopathy. Retrospective analysis of brain CT scans and clinical data. Tertiary care hospital ICUs. Patients with acute or acute-on-chronic liver failure and severe hepatic encephalopathy. Clinically indicated CT scans and serum laboratory studies. Change in intracranial cerebrospinal fluid volume between sequential CT scans was measured as a biomarker of acute brain volume change. Corresponding changes in serum osmolality, chemistry measurements, and Glasgow Coma Scale were determined. Associations with cerebrospinal fluid volume change and Glasgow Coma Scale change for initial volume change assessments were identified by Spearman's correlations (rs) and regression models. Consistency of associations with repeated assessments was evaluated using generalized estimating equations. Forty patients were included. Median baseline osmolality was elevated (310 mOsm/Kg [296-321 mOsm/Kg]) whereas sodium was normal (137 mEq/L [134-142 mEq/L]). Median initial osmolality change was 9 mOsm/kg (5-17 mOsm/kg). Neuroimaging consistent with increased brain volume occurred in 27 initial assessments (68%). Cerebrospinal fluid volume change was more strongly correlated with osmolality (r = 0.70; p = 4 × 10) than sodium (r = 0.28; p = 0.08) change. Osmolality change was independently associated with Glasgow Coma Scale change (p = 1 × 10) and cerebrospinal fluid volume change (p = 2.7 × 10) in initial assessments and in generalized estimating equations using all 103 available assessments. Acute decline in osmolality was associated with brain swelling and neurologic deterioration in severe hepatic encephalopathy. Minimizing osmolality decline may avoid neurologic deterioration.

Motor network recovery in patients with chronic spinal cord compression: a longitudinal study following decompression surgery.

OBJECTIVE The authors used functional MRI to assess cortical reorganization of the motor network after chronic spinal cord compression and to characterize the plasticity that occurs following surgical intervention. METHODS A 3-T MRI scanner was used to acquire functional images of the brain in 22 patients with reversible cervical spinal cord compression and 10 control subjects. Controls performed a finger-tapping task on 3 different occasions (baseline, 6-week follow-up, and 6-month follow-up), whereas patients performed the identical task before surgery and again 6 weeks and 6 months after spinal decompression surgery. RESULTS After surgical intervention, an increased percentage blood oxygen level-dependent signal and volume of activation was observed within the contralateral and ipsilateral motor network. The volume of activation of the contralateral primary motor cortex was associated with functional measures both at baseline (r = 0.55, p < 0.01) and 6 months after surgery (r = 0.55, p < 0.01). The percentage blood oxygen level-dependent signal of the ipsilateral supplementary motor area 6 months after surgery was associated with increased function 6 months after surgery (r = 0.48, p < 0.01). CONCLUSIONS Plasticity of the contralateral and ipsilateral motor network plays complementary roles in maintaining neurological function in patients with spinal cord compression and may be critical in the recovery phase following surgery.

Application of non-invasive electric stimulation of the spinal cord in motor rehabilitation of children with consequences of vertebral and cerebrospinal injury (preliminary report)

Introduction. Vertebral and cerebrospinal injury and its consequences constitute an important problem in modern medicine. In recent years, studies have shown that percutaneous electric stimulation in patients with these injuries can influence the neuronal networks of different parts of the spinal cord to activate afferent and efferent reflex connections with complete or partial disorders of supraspinal influences of various geneses.&#x0D; Aim. To investigate the effect of percutaneous electric stimulation of the spinal cord on the dynamics of recovery of neurological functions in children with vertebral and cerebrospinal injury.&#x0D; Materials and methods. Seven patients aged 4 to 18 years with lesions of the spinal cord from C5-C6 to Th12-L1 and who mainly had a marked neurological deficit were examined from 1 month to 9 years after surgical treatment. All patients underwent neurophysiological studies, including electroneuromyography, electromyography, and somatosensory-evoked potentials. The patients and their parents kept a diary of urination.&#x0D; Results. This clinical study showed that percutaneous electric stimulation of the spinal cord contributed to the rapid and complete restoration of the neurological functions in patients with vertebral and medullar conflict and depended directly on the early terms of surgical intervention.&#x0D; Conclusion. The positive results obtained in the complex rehabilitation of children with vertebral and cerebrospinal injuries by using non-invasive percutaneous electric stimulation of the spinal cord support the use of this method in the early stages after surgical intervention.

Early Selective Serotonin Reuptake Inhibitors for Recovery after Stroke: A Meta-Analysis and Trial Sequential Analysis

Potential benefits and risks of early (≤30 days from stroke onset) selective serotonin reuptake inhibitors (SSRIs) treatment for neurologic functional recovery after stroke are not fully understood. We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials that assessed SSRI medications during the initial ictus after stroke versus placebo. Primary outcome was decrease in National Institutes of Health Stroke Scale (NIHSS) score. Secondary outcomes included the improvement of Barthel index, functional independence (modified Rankin Scale score 0-2 at the end of follow-up), the incidence of depression, and adverse events including diarrhea, insomnia, hepatic enzyme disorders, seizure, and intracranial hemorrhage. We used fixed effects models or random effects models to estimate weighted mean differences (WMDs) and relative risks (RRs) with 95% confidence intervals (CIs) according to heterogeneity. Eight trials were included, with 1549 patients. Compared with placebo, decrease in NIHSS was greater in SSRI-treated patients (WMD, 0.82; 95% CI, 0.31-1.33; P = .002). Trial sequential analysis showed that the cumulative z curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. Early SSRI treatment also promoted Barthel index (WMD, 5.32; 95% CI, 1.65-8.99; P = .005) and functional independence (RR, 2.54; 95% CI, 1.82-3.55; P < .0001). There was no difference in the incidence of depression and adverse events between groups. No evidence of publication bias was detected. The early SSRIs treatment reduces the defective neurologic function in patients undergoing rehabilitation after stroke.

Macrophage enzyme and reduced inflammation drive brain correction of mucopolysaccharidosis IIIB by stem cell gene therapy.

Mucopolysaccharidosis IIIB is a paediatric lysosomal storage disease caused by deficiency of the enzyme α-N-acetylglucosaminidase (NAGLU), involved in the degradation of the glycosaminoglycan heparan sulphate. Absence of NAGLU leads to accumulation of partially degraded heparan sulphate within lysosomes and the extracellular matrix, giving rise to severe CNS degeneration with progressive cognitive impairment and behavioural problems. There are no therapies. Haematopoietic stem cell transplant shows great efficacy in the related disease mucopolysaccharidosis I, where donor-derived monocytes can transmigrate into the brain following bone marrow engraftment, secrete the missing enzyme and cross-correct neighbouring cells. However, little neurological correction is achieved in patients with mucopolysaccharidosis IIIB. We have therefore developed an ex vivo haematopoietic stem cell gene therapy approach in a mouse model of mucopolysaccharidosis IIIB, using a high-titre lentiviral vector and the myeloid-specific CD11b promoter, driving the expression of NAGLU (LV.NAGLU). To understand the mechanism of correction we also compared this with a poorly secreted version of NAGLU containing a C-terminal fusion to IGFII (LV.NAGLU-IGFII). Mucopolysaccharidosis IIIB haematopoietic stem cells were transduced with vector, transplanted into myeloablated mucopolysaccharidosis IIIB mice and compared at 8 months of age with mice receiving a wild-type transplant. As the disease is characterized by increased inflammation, we also tested the anti-inflammatory steroidal agent prednisolone alone, or in combination with LV.NAGLU, to understand the importance of inflammation on behaviour. NAGLU enzyme was substantially increased in the brain of LV.NAGLU and LV.NAGLU-IGFII-treated mice, with little expression in wild-type bone marrow transplanted mice. LV.NAGLU treatment led to behavioural correction, normalization of heparan sulphate and sulphation patterning, reduced inflammatory cytokine expression and correction of astrocytosis, microgliosis and lysosomal compartment size throughout the brain. The addition of prednisolone improved inflammatory aspects further. Substantial correction of lysosomal storage in neurons and astrocytes was also achieved in LV.NAGLU-IGFII-treated mice, despite limited enzyme secretion from engrafted macrophages in the brain. Interestingly both wild-type bone marrow transplant and prednisolone treatment alone corrected behaviour, despite having little effect on brain neuropathology. This was attributed to a decrease in peripheral inflammatory cytokines. Here we show significant neurological disease correction is achieved using haematopoietic stem cell gene therapy, suggesting this therapy alone or in combination with anti-inflammatories may improve neurological function in patients.

Thrombectomy with Solitaire stent for treating acute middle cerebral artery occlusion

Objective To assess the efficacy and safety of thrombectomy with Solitaire stent for treatment of acute middle cerebral artery occlusion (MCAO), and to identify the predictive factors for clinical outcome. Methods A total of 25 patients with acute middle cerebral artery (MCA)-M1 segment occlusion were treated by thrombectomy with Solitaire stent. Time from onset to femoral artery puncture, time from femoral artery puncture to recanalization, times of thrombectomy, thrombolytic therapy or not, balloon dilatation and/or stent implantation, intraarterial thrombolysis or not, tirofiban treatment after therapy or not were recorded. Vascular recanalization immediately after procedure was evaluated by Thrombolysis in Cerebral Infarction (TICI). National Institutes of Health Stroke Scale (NIHSS) was used to evaluate neurological function of patients 24 h after operation, and the clinical outcomes were assessed by modified Rankin Scale (mRS) at 90 d after treatment. The occurrence rate of symptomatic intracranial hemorrhage within 24 h after operation and mortality within 90 d after treatment were recorded. Results Median time from onset to femoral artery puncture was 5.00 (4.00, 6.30) h; median time from femoral artery puncture to recanalization was 2.00 (2.00, 2.50) h; times of thrombectomy was 2 (2, 2); 7 patients (28%) received intravenous thrombolysis before thrombectomy; 6 patients (24%) underwent balloon dilatation only; 3 patients (12%) underwent stent implantation only; 4 patients (16%) underwent balloon dilatation and stent implantation; 4 patients (16%) received intraarterial thrombolysis after thrombectomy; 11 (44%) received tirofiban therapy after operation. There were 20 patients (80% ) of recanalization with TICI 2b-3 grade. The NIHSS score at 24 h after operation was significantly decreased than before procedure [8 (4, 12) score vs. 14 (11, 17) score; Z = -3.532, P = 0.000]. Symptomatic intracranial hemorrhage occurred in 3 patients (12%). At 90 d after treatment, 15 patients (60%) had favorable prognosis (mRS ≤ 2 score). Two patients (8%) died. Univariate and multivariate forward Logistic regression analysis showed the TICI 2b-3 grade was independent factor for favorable prognosis ( OR = 0.316, 95% CI: 0.102-0.982; P = 0.046). Conclusions Thrombectomy with Solitaire stent is safe and effective for treating acute MCAO. With the increase of TICI grade, the prognosis is better. DOI: 10.3969/j.issn.1672-6731.2017.11.004

The surgical treatment of metastatic spine tumors within the intramedullary compartment.

OBJECTIVE Metastasis to the spinal cord is rare, and optimal management of this disease is unclear. The authors investigated this issue by analyzing the results of surgical treatment of spinal intramedullary metastasis (IM) at a major cancer center. METHODS The authors retrospectively reviewed the medical records of 13 patients who underwent surgery for IM. Patients had renal cell carcinoma (n = 4), breast carcinoma (n = 3), melanoma (n = 2), non-small cell lung cancer (n = 1), sarcoma (n = 1), adenoid cystic carcinoma (n = 1), and cervical cancer (n = 1). Cerebrospinal fluid was collected before surgery in 11 patients, and was negative for malignant cells, as was MRI of the neuraxis. Eleven patients presented with neurological function equivalent to Frankel Grade D. RESULTS Radiographic gross-total resection was achieved in 9 patients, and tumor eventually recurred locally in 3 of those 9 (33%). Leptomeningeal disease was diagnosed in 4 patients after surgery. In the immediate postoperative period, neurological function in 6 patients deteriorated to Frankel Grade C. At 2 months, only 2 patients remained at Grade C, 8 were at Grade D, and 1 had improved to Grade E. One patient developed postoperative hematoma resulting in Frankel Grade A. Radiotherapy was delivered in 8 patients postoperatively. The median survival after spine surgery was 6.5 months. Three patients are still living. CONCLUSIONS Surgery was performed as a last option to preserve neurological function in patients with IM. In most patients, neurological function returned during the immediate postoperative period and was preserved for the patients' remaining lifetime. The data suggest that surgery can be effective in preventing further decline in selected patients with progressive neurological deficit.

Low-Dose Tissue Plasminogen Activator in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Intravenous thrombolysis using tissue plasminogen activator (tPA) improves significantly the neurologic function in patients with acute ischemic stroke (AIS). However, it brings financial burden to patients and is associated with symptomatic intracranial hemorrhage (SICH). Whether low-dose tPA can effectively reduce SICH and has the same efficacy as standard-dose tPA is still controversial. We searched for English clinical trials published before March, 2017on the comparison of the efficacy and safety between low and standard dose of tPA in the treatment of AIS using MEDLINE, Embase, and Cochrane Library. The modified Rankin scale (mRS) score was used as the primary efficacy outcome. The mRS1 corresponded to 0-1, whereas mRS2 corresponded to 0-2. The SICH and mortality were adopted as primary safety outcomes. Twelve high-quality studies were selected, including 7686 patients (low-dose: 2888, standard-dose: 4798). With no statistical heterogeneity, the fixed effects model was adopted in the analysis. Similarly to standard doses, low-dose tPA improved the mRS scores (mRS1: odds ratio [OR] = .92, 95% confidence interval [CI] .84-1.02; P = .12; mRS2: OR = .97, 95% CI .88-1.08; P = .57). Compared with standard-dose tPA, low-dose tPA reduced the incidence of SICH (by National Institute of Neurological Disorders and Stroke [NINDS] definition: OR = .71, 95% CI .57-0.89; P = .003; by Safe Implementation of Thrombolysis in Stroke Monitoring Study [SITS-MOST] definition: OR = .64, 95% CI .42-0.99; P = .04), while both reduced mortality (OR = .87, 95% CI .74-1.02; P = .08). Low-dose tPA is comparable to standard-dose tPA in improving the neurologic function and reducing mortality in AIS patients. Moreover, low-dose tPA can reduce the incidence of SICH compared with standard-dose tPA. Therefore, low-dose tPA is highly recommended in AIS patients.

The neurological outcome of radiotherapy versus surgery in patients with metastatic spinal cord compression presenting with myelopathy

PurposeWhile radiotherapy is generally an acceptable treatment for metastatic spinal cord compression, surgical intervention is controversial due to the invasiveness and diversity of diseases in the patients being considered. The ideal treatment, therefore, depends on the situation, and the most acute treatment possible is necessary in patients presenting with myelopathy. We compared the neurological outcomes between radiotherapy and surgery in patients with metastatic spinal cord compression presenting with myelopathy.MethodsA total 54 patients with metastatic spinal cord compression presenting with myelopathy treated in our institution between 2006 and 2016 were analyzed retrospectively. Twenty patients were selected by radiotherapy alone (radiation group), and 36 patients were selected by decompression and stabilization surgery with or without radiotherapy (surgery group). The neurological outcomes and complications were compared between the two treatment groups.ResultsSeven patients initially in the radiation group underwent surgery because of a substantial decline in their motor strength during radiotherapy. One of the remaining 13 patients (8%) in the radiation group and 30 of the 34 patients (88%) in the surgery group showed improvement in their neurological symptoms (P < 0.01). One patient (8%) in the radiation group and 21 patients (62%) in the surgery group were ambulatory after treatment (P < 0.01). There were no major complications related to radiotherapy, but surgery-related complications occurred in 9 of 34 (26%) patients, and 6 (18%) patients needed reoperation.ConclusionsSurgical decompression and stabilization may be required to improve the neurological function in patients with metastatic spinal cord compression presenting with myelopathy. However, the high rate of complications associated with surgery should be taken into consideration.

Normobaric Hyperoxia Reduces Blood Occludin Fragments in Rats and Patients With Acute Ischemic Stroke.

Damage of the blood-brain barrier (BBB) increases the incidence of neurovascular complications, especially for cerebral hemorrhage after tPA (tissue-type plasminogen activator) therapy. Currently, there is no effective method to evaluate the extent of BBB damage to guide tPA use. Herein, we investigated whether blood levels of tight junction proteins could serve as biomarker of BBB damages in acute ischemic stroke (AIS) in both rats and patients. We examined whether this biomarker could reflect the extent of BBB permeability during cerebral ischemia/reperfusion and the effects of normobaric hyperoxia (NBO) on BBB damage. Rats were exposed to NBO (100% O2) or normoxia (21% O2) during middle cerebral artery occlusion. BBB permeability was determined. Occludin and claudin-5 in blood and cerebromicrovessels were measured. Patients with AIS were assigned to oxygen therapy or room air for 4 hours, and blood occludin and claudin-5 were measured at different time points after stroke. Cerebral ischemia/reperfusion resulted in the degradation of occludin and claudin-5 in microvessels, leading to increased BBB permeability in rats. In blood samples, occludin increased with 4-hour ischemia and remained elevated during reperfusion, correlating well with its loss from ischemic cerebral microvessels. NBO treatment both prevented occludin degradation in microvessels and reduced occludin levels in blood, leading to improved neurological functions in rats. In patients with AIS receiving intravenous tPA thrombolysis, the blood occludin was already elevated when patients arrived at hospital (within 4.5 hours since symptoms appeared) and remained at a high level for 72 hours. NBO significantly lowered the level of blood occludin and improved neurological functions in patients with AIS. Blood occludin may be a clinically viable biomarker for evaluating BBB damage during ischemia/reperfusion. NBO therapy has the potential to reduce blood occludin, protect BBB, and improve outcome in AIS patients with intravenous tPA thrombolysis. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02974283.

Effect of intravenous thrombolysis with different doses of alteplase on neurological function in patients with acute ischemic stroke

Objective To investigate the effect of intravenous thrombolysis with different doses of alteplase on neurological function in patients with acute ischemic stroke. Methods 120 patients with acute ischemic stroke were selected as the research subjects.According to the admission time, the patients were divided into the observation group and the control group, 60 patients in each group.The observation group was treated with low dose alteplase(0.6mg/kg), the control group was given standard dose(0.9mg/kg). The clinical curative effect, incidence rate of adverse event, NIHSS score and mRS score before and after treatment were observed and recorded in the two groups. Results Before treatment, there was no significant difference between the two groups in NIHSS score(t=0.288 0, P=0.773 9). After treatment for 3 days, the NIHSS score of the control group decreased compared with before treatment, and was lower than that of the observation group at the same period, there was significant difference between the two groups(t=0.778 5, P=0.000 0). Before treatment, the mRS score between the two groups had no siginificant difference(t=0.801 0, P=0.424 7). After treatment for 90 days, the mRS score of the two groups decreased, the difference was statistically significant(t=6.811 5, P=0.000 0). After treatment, 1 patient with cerebral hemorrhage was observed in the observation group, while 3 cases in the control group, the difference between the two groups was not statistically significant(χ2=1.034 5, P=0.309 1). The mortality of the observation group was 11.47%, which of the control group was 1.67%, there was significant difference between the two groups(χ2=4.821 4, P=0.028 1). The good prognosis rate of the observation group was 45%, which of the control group was 68.33%, the difference was significant between the two groups (χ2=6.651 6, P=0.009 9). Conclusion Standard dose of alteplase in the treatment of acute ischemic stroke has better efficacy than low-dose alteplase, it has improved conditions of neurological deficits in patients, better recovery of neurological function, the prognosis is good, it can be widely recommended. Key words: Stroke; Brain ischemia; Alteplase; Thrombolytic therapy

El rol de la radioterapia holocraneal en los pacientes de mal pronóstico con metástasis cerebrales

ObjectivesIn this study we analysed the results of whole brain radiotherapy (WBRT) compared to exclusive pharmacologic treatment (EPT) regarding symptom control and improvement of neurological function in patients with brain mestastases and a poor prognosis (RPA3). MethodsFrom December 2012 to December 2014, 100 consecutive cancer inpatients with symptomatic brain mestastases were assessed in our department. We identified patients classified as RPA3 (n=37) and compared the results of patients receiving EPT (n=11) and those undergoing WBRT (n=26). ResultsThe median survival of the entire group was 1.2 months, with no statistically significant differences between EPT (0.83 months) and WBRT (1.4 months) (P=.18). Neither were differences in symptom relief observed between the 2 groups at the last follow up. Improvement of neurological signs was poor in both treatment groups. Symptom relief and improvement of neurological function in patients undergoing WBRT showed no differences compared to radiation doses, schedules or the time from brain mestastases diagnosis to the first radiotherapy session. ConclusionsWBRT did not provide clinical benefits in control of symptoms, improvement of neurological function or survival compared with EPT. In RPA3 inpatients EPT may be a reasonable option of treatment.

Observation of clinical effects of recombinant human erythropoietin combined with methylprednisolone sodium succinate in the treatment of acute spinal cord injury

Objective To evaluate the effect of recombinant human erythropoietin (rhEPO) combined with methylprednisolone sodium succinate (MPSS), compared to MPSS alone, in the treatment of neurological function of patients with acute spinal cord injury (SCI). Methods Twenty-one patients presenting in hospital within less than 8 hours after acute SCI were randomly divided into two groups, the control group (10 cases) and the intervention group (11 cases). The control group was treated by MPSS combined with placebo, while the intervention group received MPSS with rhEPO.Both groups received MPSS 30 mg/kg within the first hour, and if the patient was admitted within 4 hours, MPSS would be applied in the treatment with 5.4 mg/kg per hour in the subsequent 23 hours and till 47 hours if the patient was admitted within 4-8 hours after injury.The intervention group received 500 U/kg rhEPO on admission and another 500 U/kg in the next 24 hours, compared with the control group where placebo was used.The evaluation on neurologic function recovery was made on admission, 24 h, 72 h, one week, 2 months and 6 months later, and statistical analysis was performed. Results The change in ASIA score: in the control group, the increase was seen from admission to 6 months after injury in terms of exercise, algesia and tactile sensation ( (31.2±6.6) points vs.(57.8±9.8) points, (41.4±9.5) points vs.(64.3±10.6) points, (39.2±6.8) points vs, (61.5±11.3) points), the increase also took place in the intervention group ( (29.5±7.2) points vs.(77.4±10.3) points, (39.7±7.2) points vs.(82.3±12.1) points, (37.4±6.2) points vs.(78.6±12.4) points). As time went on, the increase range in the intervention group became larger, compared with the control group.The difference between the two groups in ASLA score was statistically significant (P 0.05). Conclusion The application of MPSS combined with rhEPO within 8 hours after acute spinal injury may be more effective than MPSS with placebo in the neurologic dysfunction recovery. Key words: Recombinant human erythropoietin; Methylprednisolone sodium succinate; Spinal cord injury

Microscope Enhanced the Efficacy and Safety of Anterior Cervical Surgery for Managing Cervical Ossification of the Posterior Longitudinal Ligament.

BackgroundWe aimed to compare microscope-assisted anterior cervical surgery with traditional open-base surgery for treating cervical ossification of the posterior longitudinal ligament (OPLL).Material/MethodsPatients were grouped into microscope-assisted anterior cervical surgery group (case group, n=30) and conventional anterior cervical surgery group (control group, n=30). Baseline characteristics, intraoperative and post-operative indexes including operation time, blood loss amount, duration of hospitalization, visual analogue scale (VAS), and complication rate were recorded. The neurological functions of patients were assessed using the Japanese Orthopaedic Association (JOA) score. Furthermore, the corresponding rate of improved JOA score (RIS) in each group was also calculated to evaluate surgery outcomes.ResultsThe average blood loss amount and hospital stay duration in the case group were lower than in the control group (p<0.05). The post-operative VAS scores of both groups were decreased significantly. Particularly the post-operative VAS score in the case group was significantly lower than that in the control group (p<0.05). While the improvement rate of JOA scores in the case group was significantly higher than that in control group after cervical spine surgery. A significantly higher RIS rate was observed in the case group (p<0.05). Furthermore, post-operative complications of patients in the case group were lower than those in the control group (p<0.05).ConclusionsCompared to conventional anterior cervical surgery, surgeries operated with microscope exhibit higher efficacy and safety including less bleeding amount, shorter operation time, released pain degree, improved neurological functions, and fewer incidences of complications.

Treatment strategies and outcomes of spontaneous spinal epidural hematomas

Objective To investigate the treatment strategies and neurological outcomes of spontaneous spinal epidural hematomas (SSEH). Methods From June 2004 to March 2016, a total of 42 patients with SSEH were admitted to Department of Neurosurgery, Tianjin Medical University General Hospital and were retrospectively reviewed in this study. All patients were divided into the surgery group (24 cases) and conservative treatment group (18 cases). Based on the time interval from inital symptoms to surgery, the patients in surgery group were further separated into 24 h group. The neurological functions of patients were assessed by the Japanese Orthopedics Association (JOA) scale and American Spinal Injury Association(ASIA) impairment scale. The JOA scores were used to determine the recovery rate of neurological functions. The follow-up period ranged from 4 to 34 months, with an average of 18±6 months. Results There were significant differences in the recovery rate of neurological functions between patients with different ASIA scales either in the surgery group or conservative treatment group (all P 0.05). The neurological function recovery rate in 24 h group (20.0±21.3%) (both P<0.05). Conclusions For patients graded as ASIA scale A, B, C or those with progressive decline in ASIA scale, early surgical treatment should be recommended. For patients of ASIA scale D, E or those with tendency for neurological function recovery within a short term, conservative treatment might be considered. Patients undergoing operations with higher initial ASIA scale and shorter preoperative interval tend to demonstrate better outcomes. Patients undergoing conservative treatment with higher initial ASIA scale seem more likely to achieve good outcomes. Key words: Hematoma, epidural, spinal; Prognosis; Neurosurgical procedures; Conservative management

Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke: Protocol for a randomized controlled (CANVAS) trial

ClinicalTrial.gov identifier: NCT02677415.

Clinical observation of hypertonic saline used for the treatment of acute intracranial hypertension in patients with hemorrhagic shock

Objective To observe the effect of hypertonic saline complex solution (hypertonic saline plus hydroxyethyl starch, HSH) on patients with severe cerebral trauma, high intracranial pressure and shock by the measurement of the changes of the mean arterial pressure (MAP), central venous pressure (CVP) and intracranial pressure (ICP), as well as GOS score changes followed up for 6 months, in order to determine the value of HSH treatment in severe cerebral trauma, intracranial hypertension and shock. Methods Sixty patients with severe brain injury and uncorrected hemorrhagic shock were selected, while the degree of coma was assessed by using GCS score, and shock severity was estimated by using the shock index (SI) score. The patients were randomly divided into HSH group (n=30) and mannitol group (MT group, n=30). Thirty minutes, 60 min and 120 min after administration either solution, The changes of MAP, CVP and ICP were observed in two groups, and all patients were followed up for 6 months to observe the outcomes of patients. Results There were no statistically significant differences in age, gender, GCS score, SI scores, and other medication between two groups (P>0.05), and they were comparable between two groups. After resuscitation of patients in two groups, MAP and CVP were elevated, but the effect of HSH appeared sooner and higher within 30 minutes [MAP (63.1±8.8) mmHg vs. (51.0±9.3) mmHg] (P<0.05); At the same time, ICP dropped more than 10% lower [ICP (27.3±5.9) mmHg vs. (32.8±4.1) mmHg] (P<0.05), while the effect of MT appeared more slowly in hemodynamic improvement; at 120 min, the increase in MAP and reduction in ICP in HSH group were more significant than those in MT group [MAP (65.9±13.2) mmHg vs. (60.4±7.2) mmHg] (P<0.01); the ICP [ (22.2±4.7) mmHg vs. (28.1±6.1) mmHg] (P< 0.01). Followed up for 6 months, good recovery rate in HSH group was higher and poor recovery rate was lower than those in MT group. Conclusions In patients with acute intracranial hypertension and uncorrected hemorrhagic shock, the employment of hypertonic saline plus hydroxyethyl starch solution can produce faster and more effective therapy for shock and reduce intracranial pressure, improving the long-term neurological function of patients. Key words: Intracranial hypertension; Hemorrhagic shock; Hypertonic sodium chloride; Hydroxyethyl

Clinical therapeutic guideline for neurorestoration in spinal cord injury (Chinese version 2016)

Clinical therapeutic guideline for neurorestoration in spinal cord injury (Chinese version 2016) Yaping Feng,1,* Tiansheng Sun,2,* Lin Chen,3 Jiaxin Xie,1 Zhicheng Zhang,2 Hongyun Huang,4 Xijing He5 On behalf of the Chinese Association of Neurorestoratology and Chinese Branch of the International Association of Neurorestoratology 1Department of Neurosurgery, Kunming General Hospital of People&rsquo;s Liberation Army (Spinal Cord Injury Treatment Center of People&rsquo;s Liberation Army), Kunming, Yunnan, 2Department of Orthopedics, Beijing Army General Hospital, 3Department of Neurosurgery, Yuquan Hospital, Tsinghua University, 4Institute of Neurorestoratology, General Hospital of Armed Police Forces, Beijing, 5Department of Orthopedics, The Second Affiliated Hospital of Xi&rsquo;an Jiaotong University, Xi&rsquo;an, Shaaxi, China *These authors contributed equally to this work Abstract: Restoring functions following spinal cord injury (SCI) was the most challenging task in clinical practice in the past. Fortunately, some effective neurorestorative methods have been exploited in acute, subacute, and chronic phase of SCI. There were no clinical neurorestorative therapeutic guidelines available before this document which can be followed by physicians to manage patients with acute, subacute, and chronic SCI. This guideline will be a helpful reference to physicians to implement their neurorestorative strategies that can help to improve the neurological functions in patients with SCI and their quality of life. Keywords: clinical therapeutic guideline, neurorestorative strategies, spinal cord injury, cell therapy, cordotomy, neurotization

Posterior vertebral column resection with 360-degree osteosynthesis in osteoporotic kyphotic deformity and spinal cord compression.

Osteoporotic fractures with severe kyphosis and neurologic deficits often require decompression and stabilisation. To reduce the risk of procedure-related complications, single-stage posterolateral vertebrectomy and a 360-degree fusion can be performed. An adequate reduction of kyphotic deformity through this approach has not been reported. The aim of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in osteoporotic situation. A retrospective analysis and chart review was performed for 10 consecutive patients who underwent posterolateral decompression and posterior vertebrectomy with dorsal mesh stabilisation and reduction of kyphotic deformity. Preoperative back pain was 8.6 on a visual analogue scale; it was reduced to 5.5 at discharge and 3.7 at the latest follow-up (18months). The Frankel score improved from D to E (three patients) or was equal (E). Radiological segmental kyphosis was corrected from a mean of 25° to 5° (p<0.008) postoperatively with a loss of 3° at follow-up (p<0.005). Single-stage posterolateral vertebrectomy allow for a fast and safe reconstitution/preservation of neurological function in patients with osteoporotic fracture and kyphotic deformity. A significant correction of often-accompanied hyperkyphosis is possible without neurological deterioration and with an improved sagittal profile and good pain reduction.

Cervical expensive open-door laminoplasty combined with vitamin B12 treatment for patients of cervical spondylotic myelopathy with subacute combined degeneration of the spinal cord

Objective To investigate the clinical outcome of cervical expensive open-door laminoplasty combined with vitamin B12 treatment for patients of cervical spondylotic myelopathy with subacute combined degeneration of the spinal cord. Methods Data of 10 patients with cervical spondylotic myelopathy with subacute combined degeneration of the spinal cord in February 2013 to August 2013 were retrospectively analyzed. There were 7 males and 3 females with an average age of 46 years (range, 32-73 years). Eight patients’ history was in six months, and others’ was beyond six months. All patients had undergone cervical expansive open-door laminoplasty with mini-plate fixation combined with intramuscular injection or pre os vitamin B12. Patient imaging data were used to assess the stability of the cervical spine, and spinal cord compression in the fixed position before and after their surgery. Japanese Orthopaedic Association (JOA) score was used to evaluate function, and the rate of neurological improvement was calculated. The American Spinal Injury Association was used to evaluate the neurological function inpatients be-fore and after surgery. The preoperative and postoperative numerical changes of SEP and vitamin B12 were compared using corre-lation analysis. Each dimension of preoperative and postoperative scores change was compared by Life quality evaluation F-36 scale. Results All patients were followed up for an average period of 15 months (range, 6-26 months). There were no complica-tions related to the internal fixation, such as fixation loosened or broken. Cerebrospinal fluid surrounding the spinal cord within the C3-7 range of the signal on MRI T2WI of the continuous had been recovered. JOA score increased from preoperative 9.6±2.04 to postoperative 14.7±2.04, and postoperative neurological improvement rate was 20%-80%. The excellent and good rate was 90% (9/10) including 4 excellent and 5 good. Vitamin B12 level before operation: 78.30±42.82 pg/ml, postoperative: 176.50±85.77 pg/ml. Electromyography and SEP had been all recovered. There was correlation between preoperative and postoperative vitamin B12 lev-els with spinal cord function score. According to ASIA score, there were 4 cases in C level, 6 in D level preoperatively, while 2 in C level, 5 in D level, 3 in E level postoperatively. Conclusion Cervical spondylotic myelopathy with subacute combined degen- eration of the spinal cord could be treated by surgery. Vitamin B12 by per os or intramuscular injection with removal of the cervi-cal spinal cord compression which creates a space for recovery of spinal cord could improve the surgical curative effect. Key words: Cervical vertebrae; Vitamin B12 deficiency; Subacute combined degeneration